AVISTA SENIOR LIVING NORTH MOUNTAIN

<p>Based on documentation review and interview, the manager failed to ensure that a caregiver's or assistant caregiver's skills and knowledge were verified and documented according to policies and procedures.</p><p><br></p><p><br></p><p>Findings Include:</p><p><br></p><p><br></p><p>1. A review of the facility’s policy and procedure revealed that there was no policy documented for verification of skills and knowledge for a caregiver or assistant caregiver.</p><p><br></p><p><br></p><p>2. In an interview, E11 reviewed the facility’s policy and procedure and revealed there was no policy and procedure that covered verification and documentation of a caregiver's or assistant caregiver's skills and knowledge.</p>

<p><span style="font-size: 12pt;">Based on record review, observation, documentation review, and interview, the manager failed to ensure that a caregiver provided a resident with the assisted living services in the resident's service plan</span> for one of six sampled residents.</p><p><br></p><p><span style="font-size: 12pt;"> </span></p><p><span style="font-size: 12pt;">Findings include:</span></p><p><br></p><p><span style="font-size: 12pt;"> </span></p><p><span style="font-size: 12pt;">1. A review of R6’s medical record revealed a service plan that reflected R6 required the following assistance: Grooming twice daily, dressing daily, bathing twice weekly, and toileting three times daily. A review of R6’s documentation of services provided from March 1, 2025, through March 31, 2025, and April 1, 2025, through April 31, 2025, revealed R6 was not provided with assistance with toileting three times daily or grooming twice daily. </span></p><p><br></p><p><br></p><p><span style="font-size: 12pt;">2. In an interview, E11 reviewed R6’s medical record and acknowledged that the services were not provided according to R6’s service plan.                                                             </span></p>

<p><span style="font-size: 14pt;">Based on documentation review and interview, the manager failed to ensure the disaster plan was reviewed at least every 12 months.</span></p><p><br></p><p><span style="font-size: 14pt;"> </span></p><p><span style="font-size: 14pt;">Findings include:</span></p><p><br></p><p><span style="font-size: 14pt;"> </span></p><p><span style="font-size: 14pt;">1. A review of the facility’s documentation revealed the latest disaster plan annual review was December 8, 2023.</span></p><p><br></p><p><span style="font-size: 14pt;"> </span></p><p><span style="font-size: 14pt;">2. In an interview, E11 acknowledged that a more recent annual disaster plan </span><span style="font-size: 18.6667px; background-color: rgb(255, 255, 255); color: rgb(68, 68, 68);">review </span><span style="font-size: 14pt;">was not given for review.</span></p>

<p>Based on observation review and interview, the manager failed to ensure that p<span style="font-size: 10.5pt;">oisonous or toxic materials stored by the assisted living facility</span> were maintained in a locked area and were inaccessible to residents.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. During a facility tour, the compliance officer observed the following toxin unlocked in the facility’s cabinet inside the directed care unit: a container of nail polish.</p><p><br></p><p><br></p><p><span style="font-size: 11pt; font-family: Calibri, sans-serif;">2. In an interview, E11 acknowledged that the </span><span style="background-color: rgb(255, 255, 255); color: rgb(68, 68, 68);">nail polish</span><span style="font-size: 11pt; font-family: Calibri, sans-serif;"> was not stored locked.</span></p>

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided to a resident in the resident's medical record, for one of two residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan.

Findings include:

1. A review of R1's medical record revealed an undated service plan. The service plan included the following services:
-Skin integrity checks 2 times a day;
-Grooming 2 times a day; and
-Hydration assistance with meals 2 times a day.
However, a review of R1's activities of daily living (ADL) sheets revealed the following services not documented as administered on the following dates and times:
-Grooming from November 22, 2024 to November 24, 2024 on the evening shift (2:00 PM to 10:00 PM) and November 23, 2024 to November 25, 2024 on the day shift (6:00 AM to 2:00 PM);
-Skin integrity checks from November 1, 2024 to November 24, 2024 on the evening shift and November 1, 2024 to November 25, 2024 on the day shift; and
-Hydration assistance with meals from November 1, 2024 to November 24, 2024 on the evening shift and November 1, 2024 to November 25, 2024 on the day shift.

2. In an interview, E2 and E3 reported the online system has a malfunction and are unsure why the services are not initialed as provided.

3. In an interview, E2 and E3 acknowledged services on R1's ADL sheet were not documented as provided.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver's or assistant caregiver's skills and knowledge were documented and verified before the caregiver or assistant caregiver provided services and according to policy and procedures, for one of three sampled caregivers and assistant caregivers. The deficient practice posed a risk if the employees were unable to meet a resident's needs.

Findings include:

1. A review of facility policies and procedures revealed policies titled, "Caregiver Employment Requirements" and "Assistant caregiver employment Requirements." Both policies stated, "...Needed skills and knowledge will be verified and documented prior to the caregiver providing services."

2. A review of E3's personnel record revealed E3 was hired as a caregiver. E3's personnel record contained a document used to verify skills and knowledge. However, the document was not dated, and the front page was left blank.

3. In an interview, E2 acknowledged E3's skills and knowledge verification documentation was incomplete.

Based on record review and interview, the manager failed to ensure a medication was administered to a resident in compliance with a medication order, for one of three sampled residents. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication.

Findings include:

1. A review of R2's medical record revealed a signed medication order for "Metformin 500 mg" (milligrams). Further review of R2's medical record revealed a medication administration record (MAR). The MAR revealed R2's "Metformin" was withheld at 8:00 AM on October 1-3, 2023. However, "Metformin" was documented as administered at 8:00 PM on October 1-3, 2023.

2. In an interview, E2 reported R2's "Metformin" was on hold on October 1-3, 2023 because the facility ran out of the medication and was waiting on the resident representative to provide the refill, and the documented administration of "Metformin" at 8:00 PM on October 1-3, 2023 was an error.

3. In an interview, E2 acknowledged R2's "Metformin" was not administered in compliance with an order on October 1-3, 2023.

Based on observation, documentation review and interview, a manager failed to implement policies and procedures to protect the health and safety of a resident covering resident medical records, including electronic medical records. The deficient practice posed a risk as the facility standards were not followed.

Findings include:

A.R.S. \'a7 12-2297(A) Unless otherwise required by statute or by federal law, a health care provider shall retain the original or copies of a patient's medical records as follows: If the patient is an adult, for at least six years after the last date the adult patient received medical or health care services from that provider.

1. The Compliance Officer, accompanied by E13, observed on a medication cart on the fifth floor, an unattended laptop computer. The Compliance Officer tapped on the mousepad and immediately a medical record was available for review. The medical record revealed a resident's name, medication administration record, date of birth, room number, medical information, level of care, vitals and allowed access to additional tabs on the screen, including medications, assistance with daily living tasks and assistance needed for the resident.

2. A review of the facility's undated policies and procedures revealed a policy titled, "Medication Administration Records." The policy stated, "...Team Members who have access to PHI (Protected Health Information) will follow HIPAA guidelines to protect...b) Computers are secure, password protected and screens are locked when not in use..."

3. In an interview, E13 acknowledged the Compliance Officer was able to access PHI on the laptop without any special password or knowledge.

4. In an interview, E12 acknowledged the policy indicated PHI stored on a laptop would be secured, password protected and locked and the facility had not implemented its policy to safeguard PHI.

Based on documentation review, record review and interview, the manager failed to ensure documentation required by Article 8 was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance.

Findings include:

1. The Compliance Officers requested, at 9:30 AM, documentation to be provided for the facility's complaint investigations and compliance inspection.

2. The Compliance Officers conducted the exit interview with E11 and E12 at 4:30 PM and the following documentation had not been provided to the Department for review:
-E10's cardiopulmonary resuscitation training documentation
-E7's and E10's first aid training documentation
-R3's documentation per R9-10-807.B.

3. In an interview, E12 acknowledged the aforementioned documentation was not provided to the Department within two hours after a Department request.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation of cardiopulmonary resuscitation (CPR) training, for one of ten employees sampled. The deficient practice posed a risk if E10 was unable to perform CPR during an emergency or during an accident, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of E10's (hired in 2023) personnel record revealed documentation of a CPR training card, completed in August 2022. However, the CPR training card was from an online program.

2. In an interview, E12 acknowledged E10's CPR training card was from an online program and documentation of current CPR training, with demonstration, was not available for review.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation of first aid training. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an accident, injury or emergency, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of E7's (hired in 2022) personnel record revealed current documentation of first aid training was not available for review.

2. A review of E10's (hired in 2023) personnel record revealed current documentation of first aid training was not available for review.

3. In an interview, E12 acknowleged current first aid training documentation was not available for E7 and E10.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted by the assisted living facility; signed and dated by a physician, registered nurse practitioner, registered nurse or physician assistant, for one of ten residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's need, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of R3's (admitted in 2021) medical record revealed a document titled "Medical Practitioners Plan of Care (Orders)" indicating R3 required directed care. However, the document was not signed and dated by a physician, registered nurse practitioner, registered nurse or physician assistant.

2. In an interview, the findings were discussed with E12 and no additional information or explanation was provided.

Based on observation and interview, the manager failed to ensure a resident's medical record was protected from loss, damage, or unauthorized use. The deficient practice posed a HIPPA violation risk if public health information was not protected.

Findings include:

1. The Compliance Officer, accompanied by E13, observed on a medication cart on the fifth floor, an unattended laptop computer. The Compliance Officer tapped on the mousepad and immediately a medical record was available for review. The medical record revealed a resident's name, medication administration record, date of birth, room number, medical information, level of care, vitals and allowed access to additional tabs on the screen, including medications, assistance with daily living tasks and assistance needed for the resident.

2. In an interview, E13 acknowledged the resident's medical record was not protected from loss, damage, or unauthorized use.

3. In an interview, E12 acknowledged the medical record was not protected.

Based on observation, record review and interview, the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was available and accessible in a bedroom being used by a resident receiving personal care services. The deficient practice posed a risk to the physical health and safety of a resident is a resident was unable to alert employees of a resident's needs or for emergencies.

Findings include:

1. The Compliance Officer observed R2's bedroom. The Compliance Officer pressed R2's pendant, at 10:51 AM, to check response time by personnel due to R2 reporting R2's pendant was inoperable. The Compliance Officer exited R2's bedroom at 10:59 AM and no employee had responded to the pendant alert.

2. A review of R2's (admitted in 2022) medical record revealed a service plan dated in March of 2023. The service plan indicated R2 was to receive personal care services.

3. In an interview, R2 reported R2's pendant had been pressed numerous times in the past and R2 had not received assistance or response from employees.

4. In an interview, E13 reported to be unaware of this issue with R2's pendant. E13 stated R2's bedroom had been a "dead zone."

5. In an interview, E15 ran a report and the incident where the Compliance Officer pressed R2's pendant at 10:51 AM did not appear on the report.

6. In an interview, E12 reported R2's pendant had been checked previously and had been in working order. E12 acknowledged the report ran for the pendant alerts did not contain the incident where the Compliance Officer pressed R2's pendant on May 16, 2023 at 10:51 AM.

Based on observation, record review and interview, the manager failed to ensure medication stored by the assisted living facility was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficienct practice posed a risk as R1 was not authorized to store their own medications.

Findings include:

1. The Compliance Officer observed, in R1's bedroom, unlocked and on a bedside table, the following medication:
-Tylenol Extra Strength

2. A review of R1's (admitted in 2022) medical record revealed a service plan dated in April 2023. The service plan reported R1 was to receive medication administration.

3. In an interview, E13 acknowledged the medication was not stored by the assisted living facility in a separate locked room, closet, cabinet or self-contained unit.

4. In an interview, the findings were discussed with E12 and no additional information or explanation was provided.

Based on observation and interview, the manager failed to ensure hot water temperatures were maintained between 95\'ba F and 120\'ba F in areas of the assisted living facility used by residents. The deficient practice posed a burn risk to residents.

Findings include:

1. The Compliance Officer observed the water temperature from R2's bathroom sink to be 123.6\'ba F. The temperature was measured using a Department-issued thermometer.

2. The Compliance Officer observed the water temperature from R4's bathroom sink to be 122.3\'ba F. The temperature was measured using a Department-issued thermometer.

3. The Compliance Officer observed the water temperature from R7's bathroom sink to be 124.7\'ba F. The temperature was measured using a Department-issued thermometer.

4. In an interview, E13 acknowledged the water temperatures in the resident bathrooms were not maintained between 95\'ba F and 120\'ba F.

5. In an exit interview, the findings were discussed with E12 and no additional information or explanation was provided.